A Patient Perspective of Medical Care in the US
/Part of the aftermath of making a long distance move is establishing new doctors. I’ve completed the process at this point – 8 months after the move. It’s been a learning experience. I started out with the intention to find a primary care physician and specialists in the same system so that I would only have one portal for all my medical information – unlike my legacy situation that involved at least 4 different portals. The portal for my new doctors is well organized and has become the primary way I get results and send questions/messages to my doctors. In general, the lab work is done very quickly and posted on the portal; I see it about the same time that the doctor sees it. The system of doctors – specialists – labs – hospital also includes several urgent care facilities that I appreciate; their availability can help avoid a busy ER; I’ve already used an Urgent Care facility prior to my first appointment with my new primary care doctor when I got a very painful bite that looked infected. On the downside -
Vision and dental care are not general part of ‘medical care’ from an insurance perspective or systems with MDs; vision and dental are still separate. The initial dental practice I selected wanted to do very different (and expensive) kinds of cleaning for my teeth and I’ve opted to go to a new one that is more like the dental practices I’ve used in the past. It’s hard to know how to evaluate dental recommendations since they are outside of the primary medical system. I like the vision care practice I chose but may have similar misgivings as I get closer to needing cataract surgery.
The various specialist doctors and non-blood labs/radiology are in separate buildings; they are relatively close together, but I am careful to record the building address in my appointment calendar; it’s a high traffic area and it could be challenging to get to the appointment on time if I went to the wrong building first.
Thinking about the big picture of medical care in the US - It is not achieving ‘best in world’ results based on healthy lifespan stats. Why is that?
Insurance is expensive and confusing. I’ve had health insurance since the late 1970s and the trend has been increasing cost and complexity over the duration. Checking that doctors are in-network and drugs are ones that are on the formulary is a required skill to get insurance to cover costs….and even then, sometimes surprise charges occur. What happens when your doctor prescribes a drug that is not on the insurance company’s formulary? I am very aware that I have been fortunate to always be insured….understand that the cost of good medical insurance is prohibitive to many and that often means not getting medical care until there is a health crisis…and going to an emergency room.
Cultural reluctance/aversion to embrace public health measures. Over the past decade, there has been increased resistance to public health measures (for example, not getting vaccinations for children, older adults declining vaccines, flying when sick (coughing, sneezing), and aggressively against mask wearing at any time) and demands on health professionals for treatment that is not appropriate for their condition (for example, demanding an antibiotic for a viral infection or are an ineffective drug for COVID or a drug advertised on television that is for a condition the patient does not have). I am mentioning the demands for inappropriate treatment under public health because it impacts the costs for medical care overall, increases resistance of microbes to antibiotics making them less effective when they are needed, and makes the workplace for doctors/nurses more stressful (and some decide to leave the profession resulting in shortages of skilled personnel).
Dominate lifestyle. We live in a world of fast food and ultra-processed foods…people are more sedentary because of their jobs or the type of entertainment they choose. It is harder to “eat healthy” now that when I was growing up and as a young adult. Many people in the country are obese and/or in poor physical condition. However – there are a lot healthier foods available now if we educate ourselves. For example – kale was not something I ate as child, now it is my ‘super green’; other foods that I’ve only know in the past 20 or so years include: pomegranates, edamame, beet greens, red cabbage, butternut squash, ground turkey. There are also a lot of ways to measure physical activity…and some have leveraged those metrics to become more physically fit. Still – healthy lifestyles are not as prevalent now. The bump in life expectancy that was achieved after many people managed to stop (or not start) smoking is being eroded.
Aggressive intervention with drugs. The medical system tends to treat with drugs rather than recommending lifestyle changes. Part of this skew is the way doctors are trained (often nutrition is not included in their education) and part is probably based on their experience that most patients will not follow through and make a change. If a drug can change the measure the doctor is seeing (like blood pressure or cholesterol levels), then the doctor tends to immediately medicate. Any unwanted side effects from the drugs are resolved through changing to a different drug or adding a drug to reduce the side effect or telling the patient that the benefit of the drug is greater than the impact of the side effect. But – if people can change their lifestyle, they are probably addressing the root cause of the problem rather than artificially doing something that changes the measure but leaves what is causing the problem the same. Long term maybe we’ll know if the drugs really do very much for increasing healthy lifespan.
Specialists with blinders to anything outside their specialty. The notion that a primary care physician can integrate care is overly optimistic.
Many times, the specialists are proceeding with their focus; if treatment is meeting the measures they want, side effects or over medication are not a priority for them. For example – an endocrinologist adjusting medication to get the levels of hormones to a precise level is often unconcerned or dismissive of a patient reporting heart palpitations, hot flashes, and eyebrows falling out.
Emergency room doctors are focused on resolving the primary cause of the emergency visit and sending the patient home as soon as possible; this leads to quick fixes that often do not prevent the same issue occurring repeatedly. A good example is cellulitis in older patients; the ER gives them antibiotics and they go home…often returning with cellulitis again in a month or so. If the ER is not overwhelmed and there is an alert attending in the ER or in the hospital, more proactive measures can be taken…perhaps re-evaluating the dosage levels and complexity of existing medications, adding a prophylactic antibiotic, etc. that can prevent rapidly recurring ER visits for cellulitis.
Lack of trust. Patients believe doctors may have alternative incentives than patient health when recommending treatment/drugs and doctors believing patients may not be doing as they say and/or taking meds as prescribed. Not sure how this can be bridged other than encouraging more transparency on both sides.
The bottom line – I want to believe that I am proactively maintaining my health and being a knowledgeable patient that asks relevant questions to understand my doctors’ logic….thus making the best of the medical care available…but there are certainly times that I have some doubts. So far, I have been able to resolve those doubts and am satisfied that I am on a healthy path. However - I am increasingly concerned about individuals with fewer financial resources, less healthy or not as knowledgeable. The trend is toward more challenges within the US healthcare system!
